Kan. Admin. Regs. § 129-8-13

Current through Register Vol. 44, No. 2, January 9, 2025

Section 129-8-13 - Parties

(a) The parties to each state fair hearing shall be an appellant and a respondent. The case caption in each medical assistance state fair hearing case shall identify the appellant and the respondent as follows:

(1) The named appellant in the case caption shall be the enrollee, except as specified in subsections (d) through (g). Any authorized representative of the enrollee may request a state fair hearing.

(A) A state fair hearing may be requested only by or on behalf of the appellant receiving covered services and benefits.

(B) Any appellant receiving covered services and benefits may designate, in writing, an individual or entity to request a state fair hearing and represent the appellant in a state fair hearing. The appellant shall be the only individual who can grant another individual or entity the authorization to request a state fair hearing and represent the appellant in a state fair hearing subject to the exception in paragraph (a)(1)(C).

(C) The individual or entity authorized to request a state fair hearing and represent the appellant in a state fair hearing shall not transfer written authorization to another individual or entity unless the authorized individual or entity has a power of attorney or is a guardian or conservator appointed by a court of competent jurisdiction. Any power of attorney, guardian, or conservator may authorize an individual or entity, in writing, to request a state fair hearing and represent the appellant in a state fair hearing.

(D) Written authorization, including power of attorney, letters of guardianship, or letters of conservatorship, shall accompany all state fair hearing requests made on an appellant's behalf, with the following exceptions:

(i) An unemancipated minor appellant's parent or legal guardian may request a state fair hearing on behalf of the appellant and represent the appellant in a state fair hearing without written authorization.

(ii) Any attorney-at-law retained by the appellant or the appellant's representative may request a state fair hearing on behalf of the appellant using the attorney's official letterhead or other proof of representation as written authorization.

(2) The named respondent in the case caption shall be the department that administers the program involved in the MCE's adverse benefit determination or the secretary involved in the adverse disenrollment decision, except as specified in subsection (h).

(A) If the matter involves the MCE's adverse benefit determination, the department that administers the program shall be the real party in interest. The respondent shall be the department and the case caption shall note the MCE beneath the case number. The MCE shall be an interested party in the matter. As an interested party, the MCE, in meeting its contractual responsibilities, shall review the state fair hearing matter to determine whether the following conditions are met:

(i) The MCE appeal process has been completed.

(ii) The matter was filed within the regulatory time frames.

(iii) The matter involves an adverse benefit determination.

(B) If the MCE determines that the matter has not met any of the conditions specified in paragraphs (a)(2)(A) (i)-(iii), the MCE shall submit a request to the presiding officer to dismiss the matter, subject to the approval by the department.

(C) If the matter involves an adverse disenrollment decision made by the secretary against the enrollee, the secretary shall be the real party in interest. The secretary shall be named as the respondent. The state fair hearing matter shall be reviewed by the secretary or the secretary's designee to determine whether the following conditions are met:

(i) The matter was filed within the regulatory time frames.

(ii) The matter involves an adverse disenrollment decision.

(D) If the secretary determines that the matter has not met either of the conditions specified in paragraphs (a)(2) (C)(i) and (ii), a request to the presiding officer to dismiss the matter shall be submitted by the secretary or the secretary's designee.

(b) The presiding officer conducting the state fair hearing may grant a motion to modify the case caption to clarify the parties.

(c) Any enrollee may authorize representation by legal counsel, a relative, a friend, or a spokesperson in the state fair hearing if the enrollee has authorized the representation in writing. This regulation shall not authorize the secretary or the presiding officer to grant exceptions to the Kansas supreme court rules concerning the practice of law in Kansas if the enrollee is represented by an attorney who is not licensed in Kansas.

(d) If the enrollee has died before filing a request for a state fair hearing, then an administrator or executor appointed by a court in the estate proceedings of the deceased enrollee may file the request for a state fair hearing. The appellant shall be the estate of the deceased enrollee.

(e) If the enrollee has died after filing a request for a state fair hearing, then an administrator or executor appointed by a court in the estate proceedings of the deceased enrollee may move to substitute the estate of the deceased enrollee as the appellant.

(f) The appellant may be an entity other than the enrollee in any of the following circumstances:

(1) If the matter involves a denial of an authorization for a new healthcare service made by the MCE against the enrollee, the appellant may be the provider who would have received reimbursement if the MCE had approved the authorization.

(2) If the matter involves an action by the MCE concerning a claim for payment for medical services that have already been provided to the enrollee and the enrollee will not be responsible for the payment of the medical services if the claim is denied by the MCE, the appellant may be the provider, and the case shall follow the requirements stated in article 9 of the division's regulations.

(3) If the matter involves an adverse benefit determination and an entity other than the enrollee seeks to be named the appellant, the presiding officer shall determine whether the entity seeking to be named as appellant is the real party in interest instead of the enrollee.

(g) For each state fair hearing requested by the losing party of the external independent third-party review, the appellant may be the department that administers the program or payment involved in the MCE's denial of an authorization for a new healthcare service.

(h) For each state fair hearing requested by the losing party of the external independent third-party review, the respondent may be the enrollee if the issue is a denial of an authorization for a new healthcare service.

(i) If a presiding officer allows an entity to intervene in a state fair hearing covered by this article of the division's regulations pursuant to KAPA, the intervening entity shall be identified in the caption of the case as an intervenor.

Kan. Admin. Regs. § 129-8-13

Authorized by and implementing K.S.A. 651,254 and 75-7403; adopted by Kansas Register Volume 43, No. 50; effective 12/27/2024.